Suicide: Risk Assessment and

Interventions

Kevin J. Drab, M.A., M.Ed., LPC, CAADC, CEMDRT, NBCCHBehavioral Counseling & Training Company418 Stump Road, Suite #208, Montgomeryville, PA 18936Tel: (215) 527-2904 e-mail: kjdrab@comcast.netWebsite: http://BCTPRO.com

Defining Some TermsSuicide:Death caused by self-directed injurious behavior with any intent to die as a result of the behavior.

Note: The term “committed” suicide is discouraged because it connotes the equivalent of a crime or sin. The CDC has also deemed “completed suicide” and “successful suicide” as unacceptable. Preferred terms are “death by suicide” or "died by suicide."

Suicide attempt:A non-fatal self-directed potentially injurious behavior with any intent to die as result of the behavior. A suicide attempt may or may not result in injury.

Indirect suicide:The act of setting out on an obviously fatal course without directly committing the act upon oneself. Indirect suicide is differentiated from legally defined suicide by the fact that the actor does not pull the figurative (or literal) trigger.

Examples of indirect suicide include a soldier enlisting in the army with the express intention and expectation of being killed in combat.

Another example would be "suicide by cop” in which a police officer is provoked into using lethal force against them.

High risk-taking behaviors and unhealthy lifestyles may reflect an intent to die. Studies have suggested that many more auto accidents are some form of indirect suicide than believed.

Parasuicide:Suicide attempts or gestures and self-harm where there is no result in death. It is a non-fatal act in which a person deliberately causes injury to him/herself or ingests any prescribed or generally recognized therapeutic dose in excess. Studies have found that about half of those who commit suicide have a history of parasuicide.

Self-harm (SH) or deliberate self-harm (DSH):The intentional, direct injuring of body tissue most often done without suicidal intentions. The person's primary intention is to relieve unbearable emotions, sensations of unreality, or feelings of numbness by injuring their body.

Suicidal gesturesInclude cutting, whereby the cut is not deep enough to cause significant blood loss, or taking a non-lethal overdose of medication.

Suicidal gestures are typically done to alert others of the seriousness of the individual's clinical depression and suicidal ideation, and are usually treated as actual suicide attempts by hospital staff. Some suicidal gestures do lead to death, despite the individual not having the intention of dying.

Suicide Threat:Any interpersonal action, verbal or nonverbal, stopping short of a directly self-harmful act, that a reasonable person would interpret as communicating or suggesting that a suicidal act or other suicide-related behavior might occur in the near future.

Suicidal ideation:Thoughts of suicide. These thoughts can range in severity from a vague wish to be dead to active suicidal ideation with a specific plan and intent. Although most people who undergo suicidal ideation do not commit suicide, some go on to make suicide attempts.

Some individuals habitually think of suicide, or use thoughts of suicide when in stressful situations, to enable them to feel better and more in control of a situation (in that they always have an escape).

Suicide Survivor:A friend or family member who has experienced the suicide death of someone they cared about. Grief following a suicide is always complex. Survivors don't "get over it." Instead, with support and understanding they can come to reconcile themselves to its reality.

Psychological autopsyA retrospective reconstruction of the life history of the decedent, which involves the examination of physical, psychological and environmental details of the decedent's life in order to more accurately determine the mode of death and get a better knowledge of the death process and the victim's role in hastening or affecting his own death.

This may be done for clinical purposes, used to settle criminal cases, estate issues, malpractice suits, or insurance claims.

Prevention:Interventions designed to stop suicidal behavior before it occurs. These interventions involve reducing the factors that put people at risk for suicide and suicidal behaviors. They also include increasing the factors that protect people or buffer them from being at risk.

At least 1 in 5 mental health professionals loses a patient to suicide, yet many report receiving little or no support from colleagues, supervisors or administrators.

More People Die By Suicide Than Homicide

Every 17 minutes someone dies by suicide; Every 42 seconds someone attempts suicide

More than 32,000 Americans commit suicide each year (men three times as often as women), making it the 9th leading cause of death among adults, and the 3rd leading cause of death among adolescents and children.

Annually over 200,000 individuals attempt, but do not succeed, in killing themselves (women three times as often as men).

The actual incidence of suicides in this country is very probably highly underreported for a variety of reasons, and, in any case, does not include those who have killed themselves indirectly.

As many as 50% of suiciders are intoxicated with alcohol or other drugs. Alcohol abuse is a major factor that has been found in the history of at least one fourth of all suicides examined.

Clinicians in Difficult Position Surveys across clinical disciplines consistently show #1

greatest fear is prospect of losing a client to suicide.

Many clinicians have strong – often aversive – feelings toward suicidal clients that may interfere with effective clinical care and their willingness to address the topic.

Countertransferential fear and anxieties mostly rooted in not being able to ultimately control the life-threatening behaviors of clients.

With managed care restricting admissions and lengths of hospital stays, we must find ways to form a deeper outpatient engagement and a meaningful interpersonal connection with a suicidal client.

If we truly hope to succeed with any suicidal client, we must first find a way to be “empathic of the suicidal wish,” thereby opening the door to connecting and collaborating without necessarily endorsing suicide as a means of coping with pain and suffering.

-- Jobes (2006), p.37

We learn the deepest and most effective lessons from our suicidal clients, and experience!

Suicidal individuals are neither hopeless, nor abnormalities of the human condition. Looking deeply into ourselves we find the places which could lead us to where they are.

Most people with suicidal tendencies have lost track of making their lives viable and respond well to thoughtful clinical care.

Ambivalence is a common factor in the suicidal process. Individuals can be ambivalent even when they are carrying out a suicidal act.

Most literature on suicide focuses on unpleasant internal states. Yet, relationships, role responsibility, and issues related to self are much stronger factors in suicidal ideation and intent.

Observations on Suicidal Behavior1. Asking about or exploring the possibility of suicide does not

create suicidal ideation, and, in fact, generally brings relief and hope to the person for whom no one has asked that question before.

2. Most people kill themselves because they decide to kill themselves.

3. Even up to the actual process of killing themselves, the majority are still ambivalent about their decision – a very important tool for the intervening clinician!!!!

4. It is important to realize that suicide ‘works’ at some level; it produces a solution to intense personal pain (“psychache”). As life ends, the pain ends.

5. Most suicidal people don’t want to die, they want to end their psychological pain and suffering.

6. Acceptance of the effectiveness of suicide is an important first step in a clinician’s understanding of why suicide is relatively common. We humans are a solution-oriented species.

7. Not a single piece of research has shown that the presence of any collection of risk factors can accurately predict the imminent dangerousness of a client. Nor have we found any instrument which can reliably identify or predict suicidal risk.

8. Risk factors are not necessarily causes of an event, but are merely associated in some way, e.g., high correlations of a variable (such as age or illness) with suicidal behavior does not prove cause and effect.

9. It is very likely that suicide-vulnerability is the result of certain, as of yet undetermined, combinations of biological, sociological, psychological, situational and existential variables that seem associated with suicide risk.

10. Most suicidal people have psychological problems, social problems, and poor methods for coping with pain – all things that mental health professionals are usually well-trained to treat.

11. Individuals move in and out of periods of suicidal risk, sometimes for brief periods, sometimes for moderate or long periods, as their life circumstances fluctuate.

12. In order to commit suicide numerous conditions have to exist, and even when individuals appear at high risk very few actually kill themselves.

In the suicidal state there is a pervasive feeling of helplessness-hopelessness:

‘There is nothing I can do except to commit suicide and there is no one who can help me with the pain that I am suffering.’

Underlying all of the emotions - hostility, guilt, shame - is the emotion of impotent ennui, the feeling of helplessness-hopelessness.

Shneidman’s Ten Commonalities of Suicide (1985)1. The common stimulus is unendurable psychological pain (i.e.,

psychache).2. The common stressor in suicide is frustrated psychological

needs.3. The common purpose of suicide is to seek a solution.4. The common goal of suicide is cessation of consciousness.5. The common emotion in suicide is hopelessness-helplessness.6. The common internal attitude toward suicide is ambivalence.7. The common cognitive state in suicide is constriction.8. The common interpersonal act in suicide is communication of

intention.9. The common action in suicide is egression (i.e., escape).10. The common consistency in suicide is with life-long coping

patterns.

PROTECTIVE FACTORSResearch has found that the following protective factors can counterbalance suicidal vulnerabilities:

having social supportsbeing cognitively flexible obtaining treatment (especially psychotropic medications) being a younger female being physically healthy being hopeful

They conclude that suicidal outcome is not only a joint product of risk, vulnerability, and psychiatric disorder, but also counterbalanced by protection, competency, and resilience.

Malone, et al. conclude that nonsuicidal depressed individuals had no previous history of suicide attempts, had greater survival and coping beliefs, feared social disapproval and had more moral objections.

Might we conclude from this that clinicians should spend more time doing the things that inoculate depressed individuals against suicide (e.g., instilling hope for the future, social supports, teaching coping skills, exploring moral objections to suicide as well as reasons for living) rather than just assessing and attempting to prevent risk?

THE ART OF SUICIDE ASSESSMENT AND INTERVENTION

“Currently, the major bottleneck in suicide prevention is not remediation, for there are fairly well-known and effective treatment procedures for many types of suicidal states; rather it is in diagnosis and identification.”

– Edwin Shneidman, father of modern suicidolgy.

Suicide Prediction refers to the foretelling of whether suicide will or will not occur at some future time, based on the presence or absence of a specific number of defined factors, within definable limits of statistical probability

Suicide (risk) Assessment refers to the establishment of a clinical judgment of risk in the very near future, based on the weighing of a very large mass of available clinical detail. Risk assessment carried out in a systematic, disciplined way is more than a guess or intuition – it is a reasoned, inductive process, and a necessary exercise in estimating probability over short periods.

SUICIDE: A MULTI-FACTORIAL EVENT

Neurobiology

Severe MedicalIllness

Impulsiveness

Access To Weapons

Hopelessness

Life Stressors

Family History

SuicidalBehavior

Personality Disorder/Traits

Psychiatric IllnessCo-morbidity

Psychodynamics/Psychological Vulnerability

Substance Use/Abuse

Suicide

COMPONENTS OF SUICIDE ASSESSMENT• Appreciate the complexity of suicide / multiple contributing

factors• Conduct a thorough psychiatric examination, identifying risk

factors and protective factors and distinguishing risk factors which can be modified from those which cannot

• Ask directly about suicide; The Specific Suicide Inquiry• Determine level of suicide risk: low, moderate, high• Determine treatment setting and plan• Document assessments

RISK FACTORSDemographic male; widowed, divorced, single; increases with age; white

Psychosocial lack of social support; unemployment; drop in socio-economic status; firearm access

Psychiatric psychiatric diagnosis (es); comorbidity

Physical Illness malignant neoplasms; HIV/AIDS; peptic ulcer disease; hemodialysis; systemic lupus erthematosis; pain syndromes; functional impairment; diseases of nervous system

Psychological Dimensions

hopelessness; psychic pain/anxiety; agitation; psychological turmoil; decreased self-esteem; fragile narcissism & perfectionism

Behavioral Dimensions

impulsivity; aggression; severe anxiety; panic attacks; agitation; intoxication; prior suicide attempt

Cognitive Dimensions

thought constriction; polarized thinking; rigidity

Trauma sexual/physical abuse; neglect; parental loss; traumatic events

Genetic & Familial family history of suicide, mental illness, or abuse

Areas to Evaluate in Suicide AssessmentPsychiatric Illnesses

Comorbidity; Affective Disorders; Alcohol / Substance Abuse; Schizophrenia; Cluster B Personality disorders.

History Prior suicide attempts, aborted attempts or self harm; Medical diagnoses; Family history of suicide / attempts / mental illness

Individual strengths / vulnerabilities

Coping skills; personality traits; past responses to stress; capacity for reality testing; tolerance of psychological pain

Psychosocial situation

Acute and chronic stressors; changes in status; quality of support; religious beliefs

Suicidality and Symptoms

Past and present suicidal ideation; plans, behaviors; intent; methods; hopelessness; anhedonia; anxiety symptoms; reasons for living; associated substance use; homicidal ideation

Gathering and analyzing data from a variety of sources, including documentation, testing and other evaluations (e.g., medical work-up), referral sources, individuals who know the patient, and interviewing the patient.

However, the primary source of information must always be the patient because it is from their internal world that suicide is conceived as the correct answer.

Screening for Suicide Risk

To be done either through initial use of symptom-based assessment tools or including questions about suicidal ideation within the first 5-10 minutes of a clinical interview.

Examples of reliable, quick measures commonly used: Beck Hopelessness Scale (Beck & Steer, 1988) Beck Scale for Suicide Ideation (Beck & Steer, 1991) Behavioral Health Monitor (Kopta & Lowry, 2002) Brief Symptom Inventory (Derogotis & Savitz, 1999) Columbia-Suicide Severity Rating Scale (C-SSRS) (Posner, K., et

al. 2008) http://www.cssrs.columbia.edu/docs/C-SSRS_1_14_09_Baseline.pdf

Outcome-Questionnare-45.2 (OQ-45.2) (Lambert, Burlingame, et al., 1996)

Suicide Risk CategoriesI. Baseline – Absence of an acute (i.e., crisis) overlay, no

significant stressors not prominent symptomatology. Only appropriate for ideators and single attempters.

II. Acute – Presence of acute (i.e., crisis) overlay, significant stressor(s) and or prominent symptomatology. Only appropriate for ideators and single attempters.

III. Chronic high risk – Baseline risk for multiple attempters. Absence of an acute (i.e., crisis) overlay, no significant stressors not prominent symptomatology.

IV. Chronic high risk with acute exacerbation – Acute risk category for multiple attempters. Presence of acute (i.e., crisis) overlay, significant stressor(s) and/or prominent symptomatology.

(from: Rudd, et al. 2001)

Collaborative Assessment & Management of Suicidality (CAMS) method

• Developed by Dr. David Jobes (2006).

• A specific clinical approach and a philosophy of working with suicidal clients.

• The CAMS approach conceptualizes the assessment and treatment of suicidal patients in a fundamentally different way than current conventional approaches.

• CAMS is inherently designed to help shift clinicians’ attitudes and approaches by changing our conceptualization of suicide as a clinical problem and thereby changing how we assess and treat this problem.

• Focused on keeping clients out of inpatient hospital settings.

• Clients are immediately engaged in the clinical assessment of their suicidal risk, and then the management of their own outpatient safety and stability.

• Within CAMS approach, formation of a strong and viable clinical alliance is central.

• CAMS is designed to fundamentally optimize the client’s motivation.

• CAMS approach does not focus on alleviating problems like depression, but rather concerns itself with suicidality. By maximizing alliance and motivation CAMS assists the client to develop coping and

problem-solving skills to make suicide an unnecessary option.

CAMS process of care has three distinct phases:

1) Initial “index” Assessment /Treatment Planning2) Clinical Tracking3) Clinical Outcomes

The core multipurpose tool used in all phases of the CAMS is the Suicide Status Form (SSF).

Note: see examples of SSF in your handouts packet.

Use of the SSF within CAMS enables both parties to examine and work with the client’s suicidality in a relatively objective manner.

CAMS approaches the assessment and treatment of suicidal clients in a fundamentally different way then current conventional approaches.

In the conventional approach the client is a passive recipient of a reductionistic diagnostic process which views suicide as a symptom of some central psychiatric illness which will be treated with traditional therapy and medications.

• With CAMS suicidality is understood as the central clinical problem and focus.

• While not ignoring psychiatric illness, CAMS emphasizes the importance of broader underlying issues, e.g., psychological suffering, that are suicide-specific.

• Most critically, the CAMS relational dynamic is one of collaboration, where the client – who is the expert of his or her own experience – is engaged as an active collaborator in clinical care.

Key features of Collaborative Clinical Effort

• On an equal basis – even in seating arrangement (if feasible)

• Empathetic and nonjudgmental listening

• Reassuring and affirmative

• Direct, respectful questions and suggestions

• Shift conversation to need to more deeply explore client’s pain and suffering using SSF.

INTERVIEWING THE PATIENT

Motivational Interviewing (is an example of knowledge/skills which provide effective tools to the interviewer, such as: • avoiding argumentation and direct “heavy”

confrontation; • expressing empathy through reflective listening; • supporting self-efficacy and optimism; • rolling with resistance; • identifying discrepancies between the client’s goals

or values and their current behavior.

The SSFSection A: (Client fills out with Clinician’s

guidance) • Psychological Pain• Stress – pressure• Agitation – perturbation, emotional urgency• Hopelessness• Self-Hate• Rating overall risk of suicide at this point in time.

• Suicide thoughts related to self and others.

• Reasons for Living (RFL) and Reasons for Dying (RFD).

Shneidman’s Cubic Model of Suicide

(Shneidman, 1987)

Pain(Psychache)

Press (stress)

low

high

into

lerable

Low pain

CompletedSUICIDE

Perturbation(Agitation)1 3 4 52

1

3

4

5

2

21

34

5

Section B: (Clinician fills out with Client’s guidance)This is clinician’s assessment section, including suicide plan, preparation, rehearsal, history of suicidality, current intent, etc. Possible contributing factors such as history of impulsivity, interpersonal isolation, relationship problems, substance abuse, health problems, shame, etc.

Section C: (Clinician fills out with Client in collaboration)Suicide Specific Treatment Plan which includes primary problems.

Section D: The clinician’s postsession evaluation of client. Includes MSE, Diagnoses, Assessed Overall Suicide Risk Level, and case notes.

Common Errors of Suicide Interventionists1. Superficial reassurance.2. Avoidance of strong feelings.3. Inadequate assessment of suicidal intent.4. Passive rather than active, structuring responses.5. Sidesteping the issue – don’t ask, don’t tell.6. Keeping a secret.7. Leaving the person alone.8. Feeling responsible for saving the person.9. Being shocked, morally outraged, angry or disgusted.10. Giving advice. 11. Not listening!!!!

Things to do:

1. Ask questions and be direct in your conversation. 2. Listen, using all your clinical skills, providing empathetic

support through reflection, warmth, nonjudgmental responses, paraphrasing, feedback, etc., as well as continually assessing for signs and symptoms telling you what is going on in the patient’s mind.

3. Take any suicidal complaint seriously.

4. Be confident, encouraging and optimistic.

5. Act definitively by carrying out some tangible task such as arranging a referral, one-on-one monitoring, contract for safety, medication, etc.

INTERVENTIONS

• All interventions are ultimately aimed at helping the patient to find the answer to the question: “what needs to change in you to make suicide a much less desirable option for you in the future?” Clinician and client must systematically eliminate the reasons for dying and work to develop, infuse, and increase more reasons for wanting to live.

• A person in a suicide crisis needs emotional and physical support, direction in thought and feeling, guidance to effective action, reassurance, and advice when indicated.

• The critical component, in my view, for any good intervention is your relationship with the client.

General Guidelines for Practice and Treatment

1. Establish a clear treatment plan with the client as to how suicidal thoughts, feelings, and behaviors will be managed on an outpatient basis.

2. Closely monitor and document ongoing suicidality until it resolves.

3. Consider and use all appropriate modalities (e.g., various therapies: CBT, DBT, EMDR, Behavioral Activation Therapy, journaling, exercise, couples counseling, bibliotherapy), vocational counseling, medication, etc.

4. Routinely seek professional consultation and document such.5. Document the resolution of suicidality; monitor for any

future reoccurrence.

• Learning Warning Signs (“prodromals”) - Identifying thoughts, emotions and behaviors which are or could lead to suicidal state.

• Coping/Crisis Card - List of different strategies (internal and external behaviors) client can use in case of a crisis situation. On card, smart phone, or other immediately available form.

• Developing a Hope Kit – aid to reminding individual why they want to live – can be written (such as gratitude lost), or something like a box filled with life-affirming items and meaningful mementos that instill a sense of hope. Anything that reminds client of why struggle to live is worth fighting for.

Note on Contracting for Safety!!!

The concept of contracting for safety (also known as no-suicide contracts or agreements, no-harm contracts, and suicide prevention contracts), although a popularly accepted method for managing suicidal patients for more than 30 years, has no scientific evidence to support its effectiveness.

At times, contracting is often the primary factor in clinical decision-making, justifying a lower level of intervention or concern.

The ultimate focus of suicide contracting is not on the safety agreement itself but on the process it engenders to engage staff and patient in a dynamic, meaningful relationship for identifying patient needs, encouraging disclosure of distress, and assuring consistent support and appropriate interventions.